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Original Investigation
July 2017

Economic Evaluation of Quality Improvement Interventions Designed to Prevent Hospital Readmission: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Cedars-Sinai Medical Center, Los Angeles, California
  • 2RAND Corporation, Santa Monica, California
  • 3College of Science, Virginia Polytechnic Institute and State University, Blacksburg
  • 4Jonathan and Karin Fielding School of Public Health, University of California–Los Angeles, Los Angeles
  • 5VA Greater Los Angeles Healthcare System, Los Angeles, California
JAMA Intern Med. 2017;177(7):975-985. doi:10.1001/jamainternmed.2017.1136
Key Points

Question  Are quality improvement interventions designed to reduce hospital readmissions associated with net savings to the health system?

Findings  In this systematic review and data analysis of economic evaluations based on data for more than 16 700 patients, hospital readmissions declined by an average of 12.1% among populations with heart failure and 6.3% among general populations, but net savings to the health system were variable. In general populations, interventions that involved engaging patients and caregivers were associated with similar effectiveness but substantially larger net savings to the health system than other interventions.

Meaning  Diverse interventions can be effective at reducing readmissions, but cost savings do not consistently occur. Interventions that engage patients and family members may be associated with larger net savings.

Abstract

Importance  Quality improvement (QI) interventions can reduce hospital readmission, but little is known about their economic value.

Objective  To systematically review economic evaluations of QI interventions designed to reduce readmissions.

Data Sources  Databases searched included PubMed, Econlit, the Centre for Reviews & Dissemination Economic Evaluations, New York Academy of Medicine's Grey Literature Report, and Worldcat (January 2004 to July 2016).

Study Selection  Dual reviewers selected English-language studies from high-income countries that evaluated organizational or structural changes to reduce hospital readmission, and that reported program and readmission-related costs.

Data Extraction and Synthesis  Dual reviewers extracted intervention characteristics, study design, clinical effectiveness, study quality, economic perspective, and costs. We calculated the risk difference and net costs to the health system in 2015 US dollars. Weighted least-squares regression analyses tested predictors of the risk difference and net costs.

Main Outcomes and Measures  Main outcomes measures included the risk difference in readmission rates and incremental net cost. This systematic review and data analysis is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Results  Of 5205 articles, 50 unique studies were eligible, including 25 studies in populations limited to heart failure (HF) that included 5768 patients, 21 in general populations that included 10 445 patients, and 4 in unique populations. Fifteen studies lasted up to 30 days while most others lasted 6 to 24 months. Based on regression analyses, readmissions declined by an average of 12.1% among patients with HF (95% CI, 8.3%-15.9%; P < .001; based on 22 studies with complete data) and by 6.3% among general populations (95% CI, 4.0%-8.7%; P < .001; 18 studies). The mean net savings to the health system per patient was $972 among patients with HF (95% CI, −$642 to $2586; P = .23; 24 studies), and the mean net loss was $169 among general populations (95% CI, −$2610 to $2949; P = .90; 21 studies), reflecting nonsignificant differences. Among general populations, interventions that engaged patients and caregivers were associated with greater net savings ($1714 vs −$6568; P = .006).

Conclusions and Relevance  Multicomponent QI interventions can be effective at reducing readmissions relative to the status quo, but net costs vary. Interventions that engage general populations of patients and their caregivers may offer greater value to the health system, but the implications for patients and caregivers are unknown.

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